Discharge summaries critical for nursing home patients

MADISON, Wis. — Sending thorough and timely reports to nursing homes when a patient is discharged from the hospital could help promote patient safety during the early days after a hospitalization.

Yet, these reports, which are called discharge summaries, are frequently incomplete and delayed.

That’s according to researchers at the University of Wisconsin School of Medicine and Public Health. Their findings, recently published in the Journal of General Internal Medicine, determined that reports regularly lacked necessary information about diet, activity level, therapy and pending laboratory tests of nursing home patients after departure from the hospital.

The study, which was funded by the UW Health Innovation Program and the National Institutes of Health, involved 489 Medicare patients treated for strokes and hip fractures. All were sent to nursing homes after discharge from the hospital between 2003 and 2005.

According to a requirement from The Joint Commission that accredits health care facilities, hospitals must submit discharge summaries (which provide details on the patient’s hospital stay and future care) within 30 days after a patient is discharged from the hospital. Discharge summaries often serve as the primary template for guiding the care of patients discharged to nursing homes, especially in the first few days after hospital discharge.

However, Dr. Amy Kind, assistant professor of medicine in the division of geriatrics and lead author of the study, identified a number of problems with the summaries, including the following:

• They were often completed many days after the patient had already been discharged to the nursing home, some more than 30 days after discharge.

• In addition, as the time grew longer, the quality of the information within the summaries became more poor or incomplete. This forces nursing home caregivers to spend precious time contacting the hospital to determine how to proceed with patient treatment.

“Right now, the Joint Commission standard for the creation of discharge summaries within 30 days is outdated, because this standard doesn’t optimally support patients who need care right after discharge,” she said. “Our study is the first to suggest that the quality of the actual document starts getting worse the longer you wait to create a discharge summary. Important items are omitted, and because of that, patient care may suffer.

“We know that one in five Medicare patients is rehospitalized within 30 days of discharge,” she added. “Experts suggest that care during the hospital discharge and early post-hospital period may be critical in preventing at least a portion of these rehospitalizations.”

Kind said nearly a third of discharge summaries did not include information about the patient’s dietary needs.

“If a patient had a stroke and has trouble swallowing, they may have been put on a specialized diet in the hospital,” said Kind. “If that information is not communicated to the nursing home in the discharge summary and the patient does not receive their specialized diet, it is possible the patient may choke or contract pneumonia. There could be important consequences.”

Kind added that instructions on therapy and activity needs were excluded on more than 40 percent of discharge summaries, and less than 10 percent included information about pending studies and laboratory tests.

“It makes a lot of sense to have a discharge summary completed on the day of discharge,” she said. “It’s pretty straightforward. They are an essential part of communication during the transitional care period. Our study did not specifically look at the impact of discharge summary quality on patient rehospitalization, but our future work will.”

According to Kind, the Rehospitalization Reduction Act, which is part of the health care reform legislation approved by Congress in 2010, may be a positive step in getting hospitals to provide patient health care information to nursing homes more quickly and reliably.

The act would penalize hospitals if their rehospitalization rates for patients with congestive heart failure, heart attacks and pneumonia are above a certain level, starting in 2013.

“The writers of the law said it is not acceptable for Medicare to pay for rehospitalization for one out of five patients,” said Kind. “If we can provide better care, hopefully, we can make the patients happier and save money for the system.”

Reports indicate 2 million nursing home patients require rehospitalization annually at a cost of $17 billion to the Medicare system.